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1A LICENSED CONTRACTOR DECLARATION
.�hhereby affirm under penalty of perjury that I am licensed under provisions of
�'hapter 9 (commencing with Section 7000) of Division 3 of the Business and
6 ofessionals Code, and my License is in full force and effect.
License # - Lic. Class i Exp. Date
p i
Date Signature of Contractor dlk
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the, project (Sec. 7044, Business & Professionals
Code).
() I am exempt under Section B&P.C: for this reason
Date Signature of Owner
WORKER'S COMPENSATION'DECLARATION'
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
'(;) I have and will maintain workers'. compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with thdsedprovisions.
Date` N as — I)NA Applicant , A _]-t-
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Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed undercellation.
any permit issued as a result of this applicaton agrees to', & s
& hold harmless the City of La Quinta, its officers, agents a
2. Any permit issued as a result of this application becomes
work is not commenced within 180 days from date of isspermit, or cessation of work for 180 days will subject permit
I certify that I have read this application and state that the abovenformatw SAr
correct. I agree to comply with all City, and State laws relating t u—
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for i spection purposes.
Signature (Owner/Agent) Date t+�-
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BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT,
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4 2004
S4,174.45
LA QUINTA
E DEPT.
RECEIPT
DATE
'•
BY
DATE FINALE
2-1 71L
INSPECT R'
=cf rr./
r1
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade _
Return Air
Steel
Combustion Air
Roof Deck _ Q e
Exhaust Fans
O.K. to Wrap p
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath Z
Drywall - Int. Lath lir
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test '
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection Z
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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MOUVItam .V1ea
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7) CF -4R
PASADERA
PH -6 DATE TESTED 9-29-04
Dem;
Date
-
E,MERGYeCAD
roLec ress
STEVE VAN LUE II
E
SCos
760-801-3981,. PLAN 1 2. UNITS
Builder Contact
P.O. Box 621
ALAN WEAVER'
Ph/Fax (760) 564-2044 -
Rancho Mirage, CA 92270
Telephone Sample Group Number
Cell: (760) 250-1852
Email DESNRG 9hA0L COM
Certifying Signature
Date• Sample Lot Number
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7) CF -4R
PASADERA
PH -6 DATE TESTED 9-29-04
Project Title
Date
57-125 MOUNTAIN VIEW LA QUINTA,
CA 92253 ASHBROOK COMMUNITIES
roLec ress
STEVE VAN LUE II
Builder Name
760-801-3981,. PLAN 1 2. UNITS
Builder Contact
Telephone Plan Number
ALAN WEAVER'
760-880-5504 GROUP 5.
HE ater
Telephone Sample Group Number
Ca-" #CCNAW183226 .
10-1-04 LOT 25
Certifying Signature
Date• Sample Lot Number
Firm: DESERT ENERGY SERVICES
HERS Provider:CHEERS
Street Address: P.O. BOX 621
City/State/Zip: RANCHO MIRAGE, CA. 92270
Copies to: Builder, HERS Provider
HERS RATER COMPLIANCE STATEMENT
The house was: El Tested ❑ Approved as part of sample testing but was not tested
As the HERS rater providing diagnostic testing and field verification, I certify that the houses identified on this form comply
with the diagnostic tested compliance requirements as checked on this form.
❑ The installer has provided a copy of CF -6R (Installation Certificate.
❑ Distribution system is fully ducted(i.e., does not use building cavities as plenums or platform returns in lieu of ducts)
❑ Where cloth backed, rubber adhesive duct tape is installed, mastic and drawbands are used in combination with cloth
backed, rubber adhesive duct tape to seal leaks at duct connections.
❑ MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum.6% Duct Leakage)
-
Duct Pressurization Test Results (CFM @ 25 Pa) Measured
Test Leakage Flow in CFM
If fan flow is calculated as 400cfm/ton x number of tons enter calculated
value here
If fan flow is measured enter measured value here
Leakage Percentage (100 x Test Leakage/Fan Flow)
Check Box for Pass or Fail (Pass=6% or less) ❑ ❑
Pass Fail
n
❑ THERMOSTATIC EXPANSION VALVE (TXV)
f
❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection ❑